Exercise as it relates to Disease/Effects of aerobic exercise on rheumatoid arthritis

This is a critique of the research article: Perlman S, Connell K, Clark A, Robinson M, Conlon P, Gecht M, Caldron P, Sinacore J et al. (1990). Dance-Based Aerobic Exercise for Rheumatoid Arthritis. Arthritis Health Professions Association; 3(1): 29-35

This critique was completed as part of the Health, Disease & Exercise unit, September 2019.

Background to Research
Numerous studies conducted internationally displayed multiple benefits through non-weight bearing vigorous exercise on cycle ergometers in people with RA. Rheumatoid arthritis (RA) is a chronic inflammatory medical condition where the immune system begins to attack the tissues in the joints.

Previously, it had been thought that vigorous exercise would negatively impact individuals with RA; increasing the severity of ones physical condition. The condition affects approximately 2% of the Australian population and is most common in people over the age of 75. This hypothesis hinders at an increase in sedentary behaviour amongst individuals with RA. The perceived link between exercise increasing the severity of symptoms in RA lead to a greater decrease in physical activity amongst the population of individuals with RA.

Decreases in physical activity are linked to a number of risks which negatively impact one's health. Insufficient levels of physical activity are associated with having a higher risk of developing cardiovascular disease, type 2 diabetes, becoming overweight/obese, dyslipidemic and decreasing one's overall health; both physically and mentally. In 2014-15 a study conducted by the Australian Institute of Health and Welfare displayed that 52% of Australians over the age of 18 were not meeting the recommended physical activity guidelines.

Overview
The research study was conducted over a 16 week period. Throughout the program, each week was comprised of two 2 hour sessions. Broken down further, the first hour was devoted to exercise, and the second hour to a discussion. Fifty-three subjects with RA were carefully selected to participate in the 16 week exercise intervention program. Diligent consideration was placed upon the selection of all test subjects, looking to identify individuals who required a specialised exercise due to medications which affected their heart rate.

Training program
The exercise section of the intervention was split into three parts; a 15-20 minute warm up in both seated and standing positions. A 20-30 minute session of dance-based aerobic exercise. And it concluded with 15-20 minutes of recovery, focused on flexibility and muscle strengthening. Dance routines were implemented to interpret the movements each individual use in everyday life. The discussion component of the program assisted in promoting the awareness of one’s own psychological state post exercise.

Assessments
Throughout the duration of the experiment a number of tests were taken to observe a variety of measures. Both pre- and post- intervention measures were taken to record any impacts the exercise intervention had on disease status, and physical and psychological function. A subset of 21 individuals from the study were also required to complete five visual scales. These scales were an addition to physiological and psychological assessments and were specifically constructed to establish each individual’s perception of how RA impacted their life. Participants were required to answer five questions on a scale of 1 to 10. The questions focused on how each individual perceived themselves, these questions were:
 * 1) How well are you doing?
 * 2) How much has your arthritis prevented you from doing the things you wanted to do?
 * 3) How aware of arthritis discomfort have you been?
 * 4) How able were you to carry on activities important to you?
 * 5) How determined were you to carry on activities important to you?

Disease status was determined using the Arthritis Impact Measurement Scales (AIMS) and though a joint examination. AIMS is a set of scales from 0-10 which allowed individuals to provide self-reported measures on their perceived health condition. AIMS is broken down into ten subscales which evaluated various areas of the individual’s life that the condition affected. Joint examination focused on measuring the swelling and pain on numerous joints. These examinations were reported on a scale of 0 to 3; where 3 illustrated severe joint pain.

Physical function was measured through a 50-foot walk time, and utilised four the AIMS subset scales; these scales being physical activity, mobility, activities of daily living and household activities. The test was administered by telling each individual to complete the 50-foot walk twice as fast as they could, with the second walk producing the time they recorded.

The Profile of Mood States (POMS) is a psychological scale used to determine an individual’s mood. The POMS testing involves an individual being told sixty-five different adjectives and on a scale of 0 to 5, looking to probe how each participant had felt over the previous week. POMS was adopted in the psychological function testing of the intervention, along with three of the AIMS subscales; depression, anxiety and social activity.

Results
Results are split into four categories, which are; disease status, physical function, psychological function and arthritis impact on quality of life.

Disease status
Overall the significant improvement of the participants disease status was evident during the course of the experiment. Only 14% (6 people) displayed signs and results of no change in disease status or a negative change within these four subcategories. There was no supported evidence that the negative effects in their disease status were due to the program’s physical activity.

Physical function
Firstly, the number of subjects had declined from 43 to 29 at time of post-test for the 50-foot walk. The average time of the 50-foot walk had decreased from 11.44s to 9.45s (1.99s improvement). No significant difference related to standard deviation (2.29 to 2.54) was identified within the three AIMS scales specifically; activities of daily living, mobility and household activities. Articular pain and swelling had decreased with the inclusion of the program’s physical activity.

Psychological function
No dramatic differences were identified in individual’s anxiety levels, tension, vigour, social activity or fatigued scores. These slight differences hinted at signs of improvement over time. Additionally, participants recorded major reductions of depression. AIMS scores for depression lowered from 2.05 to 1.54 (0.51 decrease) and POMS results for depression recorded a decline from 7.35 to 4.5 (2.85 decrease).

Arthritis impact on quality of life
Results suggest high levels of improvement in four out of the five quality of life specifics. These were; overall wellness (21.93 to 18.25), arthritis as an impediment (35.01 to 26.45), awareness of arthritis discomfort (23.96 to 28.82), ability to carry on important activities (25.81 to 21.74) and determination to carry on important activities (20.69 to 12.77).

Conclusion
Any recognised decline in physical or mental health cannot be attributed to the program’s exercise regime. Post-test individuals reported improved overall well-being, a greater determination to perform activities that were both important and necessary. This was due to an indicative development in their mental health regarding depression and a positive change in physical performance through activities such as the 50-foot walk. Conclusively the disease status and the physical and mental health of those with RA are improved with the implication of this program.

Practical Advice
Despite strong evidence correlating aerobic exercise and improvements in individuals with RA, it is important to take precautions when undertaking exercise. Seeking advice from a healthcare professional will provide further insight on the intensity one should be exercising at. There are a number of preventative measures that can be undertaken to prevent increased progression of RA. These measures being:
 * Decrease exposure to harmful environmental substances
 * Avoid smoking
 * Incorporate physical activity in everyday life
 * Seek professional medical advice

Further Information & Resources
Further information on RA can be sourced from the links below:
 * Arthritis Australia: Arthritis Australia - What is RA?
 * Arthritis Foundation: What is Rheumatoid Arthritis?
 * Australian Institute of Health and Welfare: Rheumatoid Arthritis
 * Arthritis Foundation: Living with Arthritis